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Peripheral Vascular Assessment Dr. Belal M. Hijji, RN, PhD April 2, 2012 Learning Outcomes By the end of this lecture, students will be able to: • Describe the structure and functions of the peripheral vascular system. • Carry out a health history focusing on the peripheral vascular system. • Carry out a physical assessment of the peripheral vascular system. 2 Structure and Function of Arteries, Veins, Lymphatic System, And Capillaries • Arteries – Blood vessels that carry nutrient-rich oxygenated blood from the heart to capillaries. Does every artery carry oxygenated blood? 3 – The arterial network is a high-pressure system that requires thick and strong arterial walls. Such walls contain elastic fibers that can stretch 4 – The major arteries of the arm are: • The brachial artery that supplies the arm. 5 – The major arteries of the leg • The femoral artery is the major supplier of blood to the legs.. 6 • Veins – Blood vessels that carry deoxygenated, nutrient-depleted, waste-laden blood from the tissues back to the heart. 7 – Blood in the veins is carried under much less pressure than in the arteries. Therefore, the vein walls are much thinner. Veins are larger in diameter than arteries and can expand if blood volume increases. 8 • Lymphatic system: – Is an integral and complementary component of the circulatory system, composed of lymphatic capillaries, lymphatic vessels, and lymph nodes – Its function is to drain excess fluid and plasma proteins from tissues and return them to venous system. 9 • Capillaries and fluid exchange: Capillaries are small blood vessels that form the connection between the arterioles and venules and allow the circulatory system to maintain the vital balance between the vascular and interstitial spaces. 10 Health Assessment • Collecting subjective data: The nursing health history. – Disorders of the PV develop gradually. – Severe symptoms may not occur unless damage is extensive. – Nurses are in position to ask questions about symptoms that the patient may consider unimportant. 11 History of Present Illness • Ask the following question to elicit important information – Have you noticed any color, temperature, or texture in your skin? • Rationale: Extremities with cold, pale, clammy skin, and thin, shiny skin with loss of hair over the lower legs arterial insufficiency. Warm skin and brown pigmentation around the ankles venous insufficiency – Do you experience pain or cramping [sudden painful involuntary contraction of a muscle] in legs? • Rationale: Intermittent claudication characterised by cramping pain may indicate arterial disease. 12 Past Health and Family History • Describe any problems you had in the past with circulation in your extremities. – Rationale: A positive history of PV disease increases risk of recurrence. • Do you have any heart or blood vessel surgeries or treatments? – Rationale: Appearance of skin and underlying tissue may be altered by previous surgery. • Do you have a family history of DM, HTN, CAD, or hypercholesterolemia? – Rationale: These disorders cause blood vessels damage. 13 Lifestyle and Health Practices • Do you smoke? – Rationale: Smoking increases the risk for chronic arterial insufficiency • Do you exercise regularly? – Rationale: Regular exercising improve PV circulation and decreases the risk for developing PV disease. • Describe the level of your stress – Rationale: Stress increases HR and BP and may contribute to PV disease. • Are you regularly taking prescribed medications to improve your circulation? – Noncompliance increases the risk for developing PV disease. 14 – Do you have ropelike, bulging, or contorted veins? • Rationale: These signs may indicate varicose veins. – Do you have any sores or open wounds on your legs? • Rationale: Arterial ulcers are usually painful, while venous ulcers are usually painless. – Do you have any swelling in your legs and feet? • Rationale: Peripheral edema results from obstruction of the lymphatic flow, venous insufficiency, or DVT. – Do you have swollen glands or lymph nodes? • Enlargement may indicate local or systemic infection. 15 • Collecting objective data: Physical exam of arms – Inspection • Look for size, venous patterns, and edema – Lymphedema [Condition of localized fluid retention and tissue swelling caused by a compromised lymphatic system] maybe caused by breast surgery. – Prominent venous patterning with edema may indicate venous insufficiency. • Observe color of hands and arms – Raynaud’s disease is caused by vasospasm of the fingers or toes. Signs and symptoms are pallor, cyanosis, redness, swelling, pain, throbbing, and coldness. 16 Raynaud’d disease Lymphedema 17 – Palpation • Palpate the fingers, hands, and arms. – A cool extremity may indicate arterial insufficiency. • Palpate to assess capillary refill – Capillary refill time > 2 seconds may indicate vasoconstriction, decreased cardiac output, shock, arterial occlusion, or hypothermia. • Palpate the radial pulse – ↑ pulse indicates hyperkinetic state, ↓ or absent pulse indicate arterial occlusion. • Palpate the epitrochlear [Inside of the upper arm, just above the elbow] lymph nodes [next slide]. – Enlargement may indicate infection in the hand or arm; this also accompanies lymphadenopathy. 18 Palpation of Epitrochlear Lymph Nodes 19 • Physical exam of the legs – Inspection, palpation, and auscultation • Look for lesions, ulcers, and edema – Ulcers with even margins result from arterial insufficiency; those with irregular edges and bleeding result from venous insufficiency – Bilateral edema may indicate CHF or lymphedema • Palpate for edema and for temperature of the feet and legs – Pitting edema is associated with CHF, liver cirrhosis, venous stasis due to insufficiency, obstruction, or prolonged standing or sitting. – Cold leg suggest arterial insufficiency; ↑warmth suggests superficial thrombophlebitis. 20 • Palpate and auscultate for femoral pulses – Weak or absent femoral pulses indicate partial or complete arterial occlusion. Bruits [A sound heard over an artery, reflecting turbulence of flow] suggest partial obstruction of the vessel and decreased blood flow to legs. • Palpate the popliteal and dorsalis pedis pulses 21 – Normal circulation can exist with undetectable popliteal pulse. – Arterial occlusion can also cause absent popliteal pulse. – The dorsalis pedis pulse is congenitally absent in 5%-10% of population. A week or absent pulse may also indicate impaired arterial circulation. 22 – Palpate the posterior tibial pulses • These are absent in about 15% of healthy people. • A weak or absent pulse may indicate partial or complete arterial occlusion. 23 – Inspect for varicosities and thrombophlebitis • Varicose veins resulting from incompetent valves, weak vein walls, or an obstruction above the varicosity. • Redness, thickening, pain, and tenderness along the vein indicate thrombophlebitis. 24